Good Intentions Are Not Enough: Having Students Analyze the Global Bioethics of Their Work

An old proverb states, “The road to hell is paved with good intentions.”

Though I rarely (if ever) say it aloud, I often have this aphorism in my head when I teach my undergraduate Global Bioethics class at Northwestern University, because it sums up an unstated but crucial objective of the class. At Northwestern and many other universities in the United States, global health as a field of study has grown substantially, and undergraduates interested in global health are inspired and enthused. They want to help, and they see any intervention as inherently helpful; something is better than nothing. But the best intentions and a desire to help are not enough.

For students to comprehend how a road paved with good intentions can lead to unethical outcomes, they need to understand how global health endeavors, including their own, fit within a longer history of “interventions into the lives of other peoples”—to use the subtitle of Packard’s 2016 book. Students must also consider their work within the historical context of the “colonial legacy of medical experimentation and coercive disease campaigns,” a context that can cause “even well-intentioned research and health interventions to trigger negative responses in the twenty-first century” (Schumaker 2011, 2). Interventions and endeavors are not inherently useful (even for something as seemingly innocuous as distributing vitamins, for example; see Roberts 2006) but are necessarily beset with ethical questions, concerns, and dilemmas, such as conducting an intervention outside one’s scope of knowledge or not understanding (or appreciating) the ramifications of an intervention. In other words, students need to be able to think critically about global health interventions.

Most of the literature on global health bioethics education addresses teaching medical students core competencies before they embark on international clinical rotations (Crump, Sugarman, and the Working Group on Ethics Guidelines for Global Health Training 2010; Melby et al. 2016). As Stewart recently noted, “a discussion about the pedagogy of teaching global health ethics is long overdue” (2015, 57). To address gaps in the literature, I will describe in this article a final paper assignment for my undergraduate Global Bioethics course, which I created with the goal of enabling students to assess their global health work critically and, by implication, why good intentions can lead to unintended consequences.

The Assignment

For the final paper assignment, students have two primary choices: they can write a retrospective ethical analysis considering the challenges that arose from their global health volunteer work or research experience, or they can write a prospective ethical analysis considering the anticipated challenges from global health volunteer or research work they are intending to do. For students who have not engaged in either domestic or international global health work and have no concrete plans to do so, I provide a scenario involving two undergraduate students leaving the United States to do research in a fictional Latin American country. Regardless of which option they choose, the students need to describe their research study or volunteer work, identify the potential or actual ethical problems they encountered or think they could encounter, and clearly discuss the relevant ethical issues. These ethical issues include those directly related to their potential or actual research or volunteer experience as well as those connected to larger ethical and moral problems they may (or did) encounter in their research or volunteer work. If the students write about research, they need to include as part of their discussion what research guidelines are relevant to their work and what ethical issues are rooted in their research design and methodology or in the history of previous research in the area. Finally, they need to describe their action plan—how they intend to address, or how they could have addressed, these ethical concerns. As part of this discussion, they need to engage with the ethical principles and concepts they learned in class, discuss possible ethical solutions to a problem, decide on a solution, and explain why they arrived at this solution.

In the Global Bioethics course, this assignment serves as a capstone intended to assess whether students have learned how to identify ethical concerns in global health interventions, apply ethical principles, and conduct an ethical analysis of such interventions. I expect them to support their analysis with what they learned from the course: (1) core medical ethical principles of autonomy, beneficence, respect for persons, and nonmaleficence; (2) research ethics (Emanuel et al. 2004) and international research ethical codes (World Medical Association 2013); (3) the ethics of undergraduate volunteering or doing research in international clinical settings (Forum on Education Abroad 2019; Hatfield, Hecker, and Jensen 2009; Lasker 2016; McCall and Iltis 2014; Bush et al. 2011); (4) the ethical principles often regarded as a central part of the emerging discipline of global bioethics, including humility, introspection, solidarity, and social justice (Pinto and Upshur 2009); and (5) the principles of collaboration and reciprocity. If this assignment is adapted for other courses that include units on ethical principles and research, it could be scaled down appropriately while keeping the focus on critical assessment, reflection, and evaluation.

To prepare students for this assignment, the course introduces them to case analysis as a means to learn the application of ethical principles. In small groups, students consider the ethics of scenarios involving medical volunteering and clinical research at both the professional and undergraduate levels of experience. After they have completed their analysis in small groups, we discuss the cases as a whole class. I explore the specifics of each case with the students and engage with them as they identify possible ethical concerns, apply ethical principles and guidelines to find resolutions to these concerns, and examine how these resolutions can be in conflict with each other. Using cases teaches them how to make an ethical assessment, perform an analysis, and construct an argument—skills they will then dem­onstrate on an individual basis in their final papers. The final paper assignment is structured to reflect the cases they have seen and analyzed throughout the course; their final paper is in many ways their own case.

Goals and Challenges

I was inspired to create this capstone after reading about an assignment Stewart designed for a graduate seminar she teaches (2015). I wanted students to regard the ethical concerns, questions, principles, and guidelines we cover in the class as tangible and to see how ethical principles and guidelines apply to their work, even (and especially) right now, not just when they have graduated and gone on to their careers. In addition, I aimed to equip them with the skills to assess, analyze, and argue for resolutions.

I have used this assignment for a few years now. One problem I’ve found is that students feel as though they need to find something unethical about which to write. To mitigate this, when I talk about this assignment, I stress that this can also be an opportunity for them to consider what makes a global health experience ethical. As an example, I let them know they can discuss how a program in which they volunteered illustrated, as opposed to violated, the ethical principles discussed in class. Another problem is that students who are not planning to participate in global health experiences, the option of completing the paper using the fictional scenario dilutes the overall objective of being self-reflective and of making the ethical questions and principles relevant and applicable to their experiences. To address this to some degree, I have allowed students to reflect upon volunteer experiences that are not strictly clinical but do involve working with people.

Self-reflection is important not just because it helps students understand how ethical principles are applicable to their work but also because ethically evaluating our own work is challenging. We naturally think of our work as important—why else would we do it? Being able to step back from one’s work and evaluate it is an important skill that requires practice. This assignment encourages students to take that step back, to consider critically interventions into the lives of other peoples, to raise ethical questions about their global health endeavors, and then to assess how the ethical concerns and questions raised by their global health work can be resolved.

I hope I have encouraged my students to continue to critically analyze those roads paved with good intentions.

References

Bush, Kathleen F., Christopher Glen, Julie Maslowsky, et al. 2011. Student Handbook for Global Engagement. University of Michigan Center for Global Health. https://open.umich.edu/find/open-educational-resources/public-health/student-handbook-global-engagement.

Crump, John A., Jeremy Sugarman, and the Working Group on Ethics Guidelines for Global Health Training. 2010. “Ethics and Best Practice Guidelines for Training Experiences in Global Health.” The American Journal of Tropical Medicine and Hygiene 83 (6): 1178–82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990028/.

Emanuel, Ezekiel, David Wendler, Jack Killen, and Christine Grady. 2004. “What Makes Clinical Research in Developing Countries Ethical?” Journal of Infectious Diseases 189 (5): 930–37.

Forum on Education Abroad. 2019. Guidelines for Undergraduate Research, Field Studies, and Independent Study Projects Abroad. Carlisle, PA: The Forum on Education Abroad. https://forumea.org/wp-content/uploads/2019/04/Guidelines-for-Undergraduate-Research-Abroad.pdf.

Hatfield, Jennifer, Kent Hecker, and Ashley Jensen. 2009. “Building Global Health Research Competencies at the Undergraduate Level.” Journal of Studies in International Education 13 (4): 509–21.

Lasker, Judith. 2016. Hoping to Help: The Promises and Pitfalls of Global Volunteering. Ithaca, NY: ILR Press.

McCall, Daniel, and Ana Iltis. 2014. “Health Care Voluntourism: Addressing Ethical Concerns of Undergraduate Student Participation in Global Health Volunteer Work.” HEC Forum 26 (4): 285–97.

Melby, Melissa K., Lawrence C. Loh, Jessica Evert, Christopher Prater, Henry Lin, and Omar A. Khan. 2016. “Beyond Medical ‘Missions’ to Impact-Driven Short-Term Experiences in Global Health (STEGHs): Ethical Principles to Optimize Community Benefit and Learner Experience.” Academic Medicine 91 (5): 633–38.

Packard, Randall. 2016. A History of Global Health: Interventions into the Lives of Other Peoples. Baltimore: Johns Hopkins University Press.

Pinto, Andrew D., and Ross E. G. Upshur. 2009. “Global Health Ethics for Students.” Developing World Bioethics 9 (1): 1–10.

Roberts, Maya. 2006. “A Piece of My Mind. Duffle Bag Medicine.” JAMA 295 (13): 1491–92.

Schumaker, Lyn. 2011. “History of Medicine in Sub-Saharan Africa.” In The Oxford Handbook of the History of Medicine, edited by Mark Jackson. Oxford: Oxford University Press.

Stewart, Kearsley. 2015. “Teaching Corner: The Prospective Case Study: A Pedagogical Innovation for Teaching Global Health Ethics.” Journal of Bioethical Inquiry 12 (1): 57–61.

World Medical Association. 2013. “WMA Declaration of Helsinki–Ethical Principles for Medical Research Involving Human Subjects.” World Medical Association. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/.


Sarah B. Rodriguez is Senior Lecturer, Global Health Studies Program, Weinberg College of Arts and Sciences; Lecturer, Medical Education, Feinberg School of Medicine; and Faculty, Medical Humanities and Bioethics Graduate Program, at Northwestern University.

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